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Misnomer

Whatever my differences with Ted Kennedy – and when it came to personality and outlook on life to say nothing of politcs, there were many – I had to admire the guy during this past year. The guy lived quite a life – and, at 77, was still actuarially a tad young to go. And he probably knew it.

So he fought like hell. He attacked his illness head-on; he threw all of his resources – and, being a Boston Brahmin from a phenomenally wealthy family, he certainly had the resources to throw – at trying to push back his brain cancer. By all accounts, he fought like a lion, living his life to the best of his ability in the meantime.

“Ted Kennedy’s dream of quality health care for all Americans will be made real this year because of his leadership and his inspiration,” Democratic House Speaker Nancy Pelosi said in a statement.

Pelosi underlined that Kennedy’s death one year after the cancer-stricken liberal icon climbed on stage at the Democratic National Convention of August 2008 and declared health care reform “the cause of my life.”

“Today, we pick up the torch and recommit ourselves to health insurance reform,” said Democratic Representative Chris Van Hollen, who leads the party’s efforts to maintain or enlarge its majority in the 2010 mid-term elections.

Democratic Senator Robert Byrd, who like Kennedy has missed some votes this year due to illness, mourned “by best friend in the Senate” and called for the health overhaul legislation to be named for the late Massachusetts lawmaker.

“In his honor and as a tribute to his commitment to his ideals, let us stop the shouting and name calling and have a civilized debate on health care reform which I hope, when legislation has been signed into law, will bear his name for his commitment to insuring the health of every American,” said Byrd.

The contradiction that none of them mention; the treatment options for a 77 year old man with a long history of alcohol abuse would be much, much more restricted than they were for Kennedy.

“Heathcare Rationing” is practiced all over the American healthcare industry, in both the private and public sectors, today. HMOs adopted “Case Management” from their inception. “Case Management” is all about answering, for a given person with a given condition, the question “For a person of a given age and with a given medical history and in a given overall condition, what will be the most cost-effective treatment option, given the limits in the amount of resources available?” Of course, behind the scenes there is a formula – how many years will a treatment likely buy a patient – and, where resources are scarce, a question: to whom should a limited set of resources go?

For a seven year old girl who develops leukemia, it’s moderately simple: aggressive, intensive treatment – say, a bone marrow transplant and intensive chemo – the $200,000 worth of treatment will likely buy 70-75 years of life span; the procedures are becoming moderately common. Approved!

For a 65 year old overweight alcoholic and two pack a day smoker with terminal cirrhosis of the liver? He has uncontrolled high blood pressure and all sorts of alcohol-related pathologies? He might get the liver transplant, if there’s a liver of his type available – and if there’s not a 30 year old marathon-running father of four with a congenital liver condition who needs it first; a smoker with hypertension and alcohol-related kidney trouble and high cholesterol might have a life expectancy of seven more years, should he get the liver and the cool half mill in supportive care; the marathon runner could get you fifty years and change. Again – a simple choice; if there’s one liver that matches both, the 30 year old will live, and the Case Manager – or the team that manages the case, perhaps – will put the 65 year old on palliative care, and medication to try to coax the liver function along, and tell him they’ll try to find another liver but to get his affairs in order anyway.

By the way – you may not call the Case Manager or CM team a “Death Panel” – but if you’re the 65 year old in the example above, the difference is only rhetorical.

So how much money did Ted Kennedy spend to eke out this past 15 months or so? It’s his money, and it’s his life, and I won’t begrudge him a dollar or a day.

But if a 77 year old man with highly-advanced brain cancer, plenty of chronic conditions related to decades of heavy drinking, and a good 60 pounds overweight went into a doctor’s office in Sweden or the UK or Canada, what do you suppose the prognosis, course of treatment, or results would have been? Not just for any given 77 year old man, mind you, but 100 of them whose profiles match each other fairly closely?

Naming a health rationing system after a man whose struggle the system would have made impossible makes sense – in the curious little world of Democrat social policy.

64 thoughts on “Misnomer”

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Justplainangry and Night Writer both make excellent and very different points concerning healthcare technology. It’s another example of the complexity of these problems. Single simple answers are frequently not adequate.

Night Writer, I agree with your free market approach to the healthcare issue. However, I don’t agree with the often-stated assumption that markets are efficient. I believe they are “sufficient,” and that is quite a different matter.

Free markets and the way they change and develop over time (evolve) follow rules that are the same as other complex adaptive systems, including biological systems. As such, the evolutionary “solution” is “sufficient.” If the solution is also “efficient,” it is quite by accident.

Justplainangry, I’ve stated several times and in several different ways that my original point was about the “questions left unanswered,” and my central concern doesn’t really depend upon who was right or who was disingenuous.

So, Justplainangry, if you wish to assert that “it is proven,” then you win and I’ll make no more bets. Let’s move on.

Leslie, thank you for stimulating discussion that goes beyond the same old same old into more genuinely challenging territory.

I particularly agree with what you said here:
“I see that as counter-productive to the discussion because it increases polarization rather than bringing people together to work out a solution we can all live with. I really am concerned about what the results might be if the right refuses to seriously enter the discussion.

What are the deal breaking issues on the left? What are the deal breaking issues on the right? How many of the other issues is the left willing to give up and what are the issues the right is willing to give in on?”

I have on multiple occassions asked for people to be less polarizing, asked them to ratchet down the name calling, labeling (especially the pejorative labels) and the assumptions. In aid of that, I try not to sling pejoratives like ‘wing nut’ or any of the ‘con’ related names in my comments.

While there are some here who will engage in ideas and who are civil and even quite cordial, as you have now experienced there are others who like plainangry instead lash out pretty quickly at those with a different point of view than their own. I found you a kindred spirit for your views that people who are opposite need to more genuinely deal with each other in good faith and with sincere good will instead of demonizing each other.

I am here because I want to listen, to try to understand positions, and I feel that conformity or agreement are not essential to either of those. Some days…some days that is easier to do than others; those other days I just feel very saddened and discouraged by the hostility, and the name calling.

Leslie, I suppose we each could do several hundred words on what we define as “efficient” and “sufficient” but I’ll leave it at this: our current U.S. health system is “sufficient”, though in some cases, just barely. Of those who have health insurance, the wide majority are happy with the care they receive. Those who don’t have insurance still have access to care but the hospitals end up eating the cost or passing it off to the insurance companies via cost-shifting. It would be more efficient if these uninsured had access to insurance, but a government model will never be efficient; that’s just not what governments do. The weakness of our current system is the 3rd-party payer model, and a nationalized version doesn’t address that problem, it magnifies it. (As PJ O’Rourke once said, “If you think healthcare is expensive now, just wait until it’s free.”)

For all of it’s flaw, our current system is still focused on benefiting the individual when it comes to providing care. When the needs of the state supplant the needs of the individual, it’s scary. Sure we may currently go overboard in trying to extend lives with the elderly or terminal, but at least here we have the option to tell our doctors, “Please, just let me die.” There are cases in England where people have gone to court (and lost) in an attempt to tell their doctors, “Please don’t kill me.”

Leslie, two cases come to mind immediately because I have written about them in the past. If you follow the links I hope you will feel that while my position is clear, I have tried to present the information in a thoughtful and balanced way.

One is the case of a man with a progressive disease that would rob him of his ability to communicate (but not think) and didn’t want to be starved to death by the UK’s National Health Service and his doctors; the high court sided with the NHS and against the man. I wrote about it here – http://thenightwriterblog.com/2009/07/28/i-dont-want-to-go-on-the-cart/ – and the link to the full article that I cited (entitled “Terminally Ill Can be Starved to Death, UK Court Rules” is here – http://www.cnsnews.com/ViewCulture.asp?Page=\Culture\archive\200508\CUL20050802a.html – though it appears the link has lapsed (being from 2005) you may still be able to find it with a search.

Most of the links in that story, too, have lapsed but I know you can Google Charlotte Wyatt because I’ve checked back on the story over the years. She was five last time I checked she was five and while her quality of life is debatable she has survived, perhaps because of the “celebrity” she achieved. I don’t know how many there are in the UK in similar situations as Leslie Burke and Charlotte Wyatt but I don’t think they are isolated cases: such decision-making is endemic when the cost-benefit-analysis is bureaucratized. Either of us, with some refined searches, could likely pick up the thread of similar cases though they’re not commonly reported. More practical, however, is to look at the writings of Dr. Ezekiel Emanuel, health adviser to President Barack Obama, health-policy adviser at the Office of Management and Budget, member of the Federal Council on Comparative Effectiveness Research and brother of WH Chief of Staff Rahm Emanuel. He has long written and advocated allocating care in favor of 15-to-40 year olds, as I described here (with links that are still very active): http://thenightwriterblog.com/2009/08/27/doctor-doctor-give-me-the-news/.

Here’s a final point that I don’t think I’ve seen anyone else cover: while you can debate the desirability of “heroic” efforts to save the very young and very old, or those with unusual and expensive conditions, the efforts to do so have paved the way to technological and therapeutic breakthroughs that are now applied in the care and recovery of more “useful” members of society.

Leslie, I just submitted a post providing several links in response to your request, but it did not appear here right away. It may have been directed into Comment Moderation because of the amount of linkage. If there was a technical problem with that comment and it doesn’t surface today I’ll either try to re-post or you can send me an email by going to the “About” page on my blog and I’ll forward these to you. My citations are “realities” as well, describing real cases that have occurred in the UK.

NW – yep. Have to wait for Mitch to process links. He probably slept in – again! I also submitted a few in response to a link that “discusses the realities of NHS” without, well, actually discussing realities…

Actually, that is not unlike the present situation with Medicare in the United States. The Medicare reimbursement rate is so low that some practitioners “opt out” and don’t service Medicare patients. This create a similar difficulty. We are fortunate that in the case of Medicare, there continues to be an adequate number of practitioners. Furthermore, what about similar situations in this country where other insurance coverage is involved?

In an attempt to find an answer, I decided to learn a bit more about the NHS (I already know a bit about Medicare, since it is now my primary health insurance coverage. My secondary coverage is TRICARE.)

Well, I found out.

There is a good reason for the fact that a shortage was created in the NHS. In the case of the NHS, a system of government-run health delivery systems (practitioners) has been put in place, while in the case of Medicare, a public option insurance policy pays for services delivered by a diverse mix of private and government-run (mostly military or veteran related) practitioner systems. Medicare does not “run” hospitals in the same sense that the NHS runs hospitals in the UK. In short, while hospitals might accept Medicare, they are not a part of Medicare.

So, in this case in the UK, when restrictions were placed on what dentists could charge for filling teeth, they began to leave the NHS and to go into private practice. In similar situations in the United States, where Medicare pays an unusually low percentage of the practitioner’s bill, the practitioner can refuse to accept Medicare patients. But in the U. S. practitioners have another option. They can raise their rates until the Medicare payment is at least adequate. You see, practitioners are not run by a U. S. style NHS.

This means that the “cost” of everything medical in the United States is a fictitious figure. It is an illusive value that changes from moment to moment depending on where the money is coming from. There are rates for people who are in the same “system” as the practitioner, for those who were referred from another “system” and for those on the Medicare “system.” Moreover, if a practitioner’s rates are not in line with the “system’s” rates (usually based upon an average of the rates of practitioners’ who are in the “system”), the payment statement sets the practitioner straight. The “system” tells the practitioner what the correct rate should have been and then bases its payment on that value. In the United States, these “systems” are insurance-based, not practitioner-based. In the UK the NHS consists of several “systems” that all appear to be practitioner-based and financed by the government. There are also non-governmental insurance-based systems and private practitioners that run in parallel to the NHS.

Apparently, in the UK rate control is enforced but it can create a shortage in the NHS. In the U.S. rate control by insurance companies actually has quite a different effect. Because of the mechanisms described above, it tends to drive up the cost of health care. Practitioner shortage is still a problem, however, because some practitioners simply drop out of one system and join another – same as with the NHS.

Notwithstanding the fact that one can find horror stories on both sides of the Atlantic, rejecting the current health care proposal because of anything that happens in the NHS is logically flawed. The NHS and the current healthcare proposal are as different as night and day.

Leslie, my view is not that we don’t need healthcare reform, only that a nationalized health plan does not solve the dysfunction in the present system and will quite likely exacerbate it. I’ve used the NHS as an example of bureaucratic cost management often at odds with the Hippocratic Oath. Going back to my (seemingly) long-ago comment about “computer insurance”, my view is that only by putting the consumer back in direct control of buying healthcare can the costs even come close to reflecting reality. To be cynical, any third-party-payer or nationalized plan turns into an exercise in gaming the system by providers for payments. To be fair to the providers, however, profit is not a bad thing and is, in fact, very necessary. I’d hazard that many of the practicioners who refuse to participate in the NHS or Medicare systems do so because the pre-determined reimbursement is not sufficient to cover their costs for providing that care. The system therefore is extracting a further subsidy from them in addition to the taxes they pay. Self-interest is a powerful thing, and it can be a very efficient thing when two parties – say someone who needs health care and someone who can provide it – can find a mutually satisfactory intersection of their interests. When a third-party gets involved – even with “good” intentions – things somehow tend to drift toward that groups interests, leaving both of the original parties unsatisfied. If we really want to reform healthcare, that’s where the revolution has to take place.

rejecting the current health care proposal because of anything that happens in the NHS is logically flawed

On the contrary, bringing up faults in NHS – an example of a single payer, government system being proposed for the USA – is a very logical step. And yes, you are indeed correct – The NHS and the current healthcare proposal are as different as night and day. Obamacare is worse then NHS.